RxIMPACT Day on Capitol Hill
March 10 & 11, 2010 • Washington, DC
Event Registration Form
One completed event registration form per participant (not company) is required.
Registrant Information
Company Name:
First Name: Middle: Last: Suffix:
Nickname (for Badge):
Professional Designation: Title:
p I am a student pharmacist attending the following school:
Phone: Ext.:
E-Mail: Fax:
Addresses
Home Mailing Address: To schedule meetings with the Members of Congress representing the address where you live and vote, please provide your
home address below, as this address is required by policymakers to schedule your meetings. This information will not be used for any other purpose
than scheduling meetings and will not be distributed.
Important note: Members of Congress will not schedule appointments with individuals listing PO Boxes or mailstops, as these are not acceptable addresses for
voter registration.
Address 1:
Address 2:
City: State/Province:
Zip/Mail Code: Country:
Physical Work Address: To increase the number of meetings we can schedule on your behalf, please also provide a second address, your physical work
address, for us to schedule a meeting with the policymakers representing your place of business. This secondary address is important as your place
of business provides goods and/or patient care services to constituents in the policymaker’s district. This information will not be used for any other
purpose than scheduling meetings and will not be distributed.
Important note: Members of Congress will not schedule appointments with individuals listing PO Boxes or mailstops, as these are not acceptable addresses.
Address 1:
Address 2:
City: State/Province:
Zip/Mail Code: Country:
1. Please indicate your connection to the community.
2. Did you participate in the 2009 RxIMPACT Day on Capitol Hill? p Yes p No
3. I am available to serve as a Team Leader. p Yes p No
4. If so, please provide a cell phone number for use during event.
5. Were you asked to participate by a Pioneer/Event Founder? Please provide us with their name.
6. If you are a Pharmacy student, please indicate at which school.
7. Please note any special disability, food menu or scheduling requirements (i.e. not available for Hill through 5 p.m. due to travel schedule) you may
have:
RxIMPACT Day on Capitol Hill
March 10 & 11, 2010 • Washington, DC
Welcome Dinner & Congressional Visits Participation
Please check all that apply:
Welcome Dinner, 7:00 p.m., Wednesday, March 10, 2010, The W Hotel, Washington, D.C.
p Yes, I will be attending the Welcome Dinner.
p No, I will not be attending the Welcome Dinner.
RxImpact Day on Capitol Hill, Thursday, March 11, 2010, Capitol Hill, Washington, D.C.
p Yes, I understand NACDS will be scheduling appointments on my behalf and I can participate in this event only if I have completed and returned
this event registration form.
Hotel Information
The W Hotel
515 15th Street, NW
Washington, D.C. 20004
Main Phone Number: 202.661.2400
W Hotel General Reservation Number: 877.946.8357
Website: www.whotels.com
NACDS Room Rate: $319.00 per night • Rate Cut-off Date: Tuesday, February 9, 2010.
Hotel reservations can be made directly with the W Hotel, Washington, D.C. by calling the hotel’s reservation department at 202.661.2400 or their
main reservation office at 877.946.8357. Be sure to mention NACDS when booking your reservation.
NACDS has secured a limited block of rooms a the special rate of $319.00 per night, single or double occupancy. Please make your reservation as
soon as possible; the hotel cut-off date is 5:00 p.m. EST Tuesday, February 9, 2010.
NACDS Contact
Please direct all questions:
Heidi Ecker
NACDS Director of Government Affairs and Grassroots Programs
Phone: 703.837.4121
Fax: 703.838.2182
E-mail: Hecker@nacds.org
Please Return Completed Event Registration Forms
to Heidi Ecker by February 10, 2010